Masked intentions: the masquerade of killing thoughts used to justify dehydrating and starving people in a "persistent vegetative state" and people with other profound neurological impairments.

• Author: Hildebrand, Adam J.

ABSTRACT: Denying food and water to profoundly impaired people who may not be conscious, or may only be "minimally" conscious, raises challenging ethical issues. While there is growing support for withdrawing/withholding food and water (assisted nutrition and hydration, or "AHN") from people described as being in a "persistent vegetative state" ("PVS") and people with other profound neurological impairments, such as advanced dementia, the issue remains controversial, and for many, unresolved.

In this article, the author argues that if a profoundly impaired person is not imminently dying from a disease process, denying food and water causes him or her to die of dehydration and starvation. When provision of food and water does not create excessive burdens (such as extreme pain and discomfort), and if the food and water can be digested and absorbed, denying such nourishment is immoral and unethical. Under these circumstances, this denial (by commission or omission) is motivated by a real intention to cause death, whether or not that intention is explicitly recognized.

Whether denial of food and water is prompted by thoughts regarding the value of a person's life, or "quality of life," or repugnance over the person's physical and mental condition, or concern over costs of care, or a desire to end the anguish of family members, or for more understandable motivations of wanting to end a person's suffering, such thoughts can be referred to as "killing thoughts."(1) Some might regard these motivations as "good" killing thoughts. But when a thought leads to an action (or an omission of an action) that directly results in someone's death, it is a killing thought. Killing thoughts express themselves through intentions to hasten death--intentional killing. I will discuss in this article how killing thoughts are disguised or "masked" in order to detoxify the reality of intentional killing. I will not go so far as to call such killing "murder," as that implies malicious, premeditated, conscious intent. While killing people in a "PVS" by dehydration and starvation can be premeditated, i.e., considered beforehand and consciously understood, usually such killing is not overtly malicious, unless of course there is malicious intent, such as wanting an inheritance sooner than later. Usually, however, the denial of food and water to people in a "PVS" is motivated by misguided compassion, and could more properly be referred to as what used to be called "mercy killing." While mercy killing may be more understandable and to some acceptable or even desirable, mercy killing is euthanasia, which is "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated."(2)

This article does not deal with complex legal decisions regarding the "AHN/ PVS" issue, nor with advance directives, informed consent, costs, or definition of death. These are relevant to the debate, but here the focus will be on the primary issue of intention and how intentions become masked and disguised. The author touches upon the analysis of benefits and burdens in decisions to withhold or withdraw food and water, but will concentrate on what he believes is the most compelling issue in the "AHN/PVS" debate--intention. He gives particular attention to the issue of providing food and water to people described as being in a "PVS" because this is the "front line" where the "AHN" battle is being fought. While the same issues apply to advanced dementia or other neurological impairments, the "PVS" issue is unique in that the very impetus for inventing the term "persistent vegetative state" was driven by masked intentions. It is instructive to note that from the very beginning when Jennett and Plum first invented the term "persistent vegetative state" in 1972,(3) they suggested that perhaps "supportive measures" should be withdrawn. They state: "If it were possible to predict soon after the brain damage had been sustained that, in the event of survival, the outcome would be a vegetative mindless state, then the wisdom of continuing supportive measures could be discussed."(4) Do these words not reveal an underlying, thinly masked intention?

Every action (or omission of an action) has intent behind it, whether or not one is conscious of that intention. An intention to cause death is always wrong. An intention to remove a burden, to relieve suffering or to prevent suffering may be valid, provided that the means is also valid. While there are a number of factors to consider in the moral analysis of provision of food and water through feeding tubes, including medical indications, prognosis, pain, costs, benefits and burdens, intention is the central moral issue in the "AHN/PVS" debate. Ideas and sentiments often mask killing thoughts that underlie intentions to cause death while enabling one to deny culpability. While such thoughts and motivations may be quite subtle or "hidden," they are no less real.

Killing Thoughts and Masked Intentions

Harvey describes the connection between wishing people dead--a manifestation of killing thoughts--and intention:

The thought of a mere body, living with no awareness of its surroundings, no ability to exchange a smile with another person, no ability to enjoy the feeling of clean sheets on a bed--it does not seem wrong to wish such a person dead, set free from the broken body that stubbornly refuses even to get sick. But to deny that this is what we want when we take away the food and water is merely self-delusion. There is no other possible outcome.(5) Ideas have consequences. When those responsible for the care and treatment of vulnerable people have the idea that some lives are not worth living, they may act (or fail to act) in ways that hasten death. Some people--people in a "PVS," those who have advanced dementia or people with other profound neurological impairments--are at risk of being hastened to death because of dehumanizing perceptions of the value of their lives. Profoundly impaired people are often thought of as non-persons, less than human, and as having no purpose in life. This dynamic generates a fundamental idea that leads one to a conclusion, even if not consciously recognized, that profoundly impaired people are better off dead.

"Quality of life" judgments so predominant today in medical ethics are a recasting of the notion that some people are better off dead. Is that not what is really being said in quality of life arguments, that a person's life is so miserable that he or she is better off dead? Wolfensberger has made a strong case for the elimination of the term "quality of life" as a hopeless, useless term that has lost all relevance and meaning.(6) Quality of life judgments are based on inexplicable, subjective criteria that judge one life as having more value than another, or one state or stage of life as having more value than another. Space does not permit detailed exploration of this issue here. Suffice it to say that while analysis of benefits and burdens of medical treatments can be valid, "quality of life" judgments subjectively assess the value of a person's life, rather than maintaining focus on the benefits and burdens of the treatments themselves.

Human action springs from internal motivation. Fundamental assumptions, ideas, thoughts and/or sentiments (or a combination of these) that lead one to conclude that certain lives are not worth living, and that some people are better off dead, spring from what I have called killing thoughts. Killing thoughts may or may not lead people to hasten the death of someone who is profoundly impaired--such thoughts may occur to most people from time to time. But if a physician, family member, surrogate decision-maker or ethicist harbors killing thoughts, and if those thoughts influence decisions to deny food and water, an intention to kill, however subtle that intention may be, is present.

Not all instances of withholding or withdrawing food and water involve intending a person's death. May et alii acknowledge that withholding or withdrawing food and fluids does not necessarily mean that one is intending to kill the patient, but is instead removing an excessive burden, or that the food and water itself is not being assimilated and is therefore useless. They state:

One may rightly choose to withhold or withdraw a means of preserving life if the means employed is judged either useless or excessively burdensome. It is most necessary to note that the judgment made here is not that the person's life is useless or excessively burdensome; rather, the judgment made is that the means used to preserve life is useless or excessively burdensome (emphasis in the original).(7) But when caregivers withhold or withdraw food and water knowing that death will result, and when in reality that is precisely what is intended, the killing thoughts that lead to those actions, though sometimes very subtle, are thoughts that intend death. The withholder is responsible for the death of a human being, no matter how good killing intentions may seem. Dolan states the principle of intentional killing as follows:

(1) A deliberate omission that causes death is morally an act of intentional killing when three conditions are satisfied:

(i) it is within the agent's power to supply what is being withheld;

(ii) the agent has an obligation to supply it; and

(iii) the agent understands that withholding what is needed is likely to cause death.(8)

Thoughts underlie intention and intention underlies action. Acts that intend death flow from thoughts that cause one to want a person dead. Wanting someone dead is not a pretty thought. The stark reality of wanting someone dead jars one's moral sensibility and is simply too much for most people to admit to themselves. The clash between harboring killing thoughts and the desire to see oneself as a good person is fertile ground for repression, denial, revisionism, reinterpretation, confusion and...